Basic Information
| Provider Information | |||||||||
| NPI: | 1700990827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LEAH LANE | ||||||||
| MiddleName: | SHUTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHUTT | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | LANE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 CLEMSON RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292294341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037886146 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Practice Location | |||||||||
| Address1: | 4568 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290729250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035205144 | ||||||||
| FaxNumber: | 8034620312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200600241 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 30653 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | BS9808354 | 01 | DEA | OTHER |